RESUMO
INTRODUCTION: Although Checklists (CL) for routine anesthesia cases have demonstrated their values in various studies, they have found little traction so far. While several reports have shown the benefit of CL preventing omissions prior to anesthesia induction, no investigation yet has scrutinized omissions during the post-induction phase immediately after intubation. This study evaluated the rate of omissions prior to and following the induction of non-emergent general anesthesia, as well as the impact of checklists on omission prevention. METHODS: We performed a monocentric, prospective, observational study during induction of general anesthesia cases. We evaluated the omission rate made for the pre- as well as the immediate post-induction phase and determined the impact of pre-and post-induction CL on the rate of omission corrections. The CL used were introduced two years prior to the study. The observed providers were limited to those familiar with the institutional CL. Usage of CL was not mandated. RESULTS: 237 general anesthesia inductions were included in the observation. At least one omission in 32% of all cases in the pre-induction setup was found and in 40% within the immediate post-induction phases. CL significantly reduced omission rates (relative risk = 0.64, 95% CI = 0.45-0.92, p = 0.01). CONCLUSION: Omission rates during the pre- and post-induction phases of routine general anesthesia procedures remain high. Pre- and post-induction CL have the potential to increase patient safety and should be considered for routine anesthesia with appropriate training provided.
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Anestesiologia , Internato e Residência , Humanos , Lista de Checagem , Estudos Prospectivos , Anestesia Geral , Anestesiologia/educaçãoRESUMO
Communicating Prognosis and Expectations in Advanced Disease - A Balancing Act in Practice Abstract. To prepare the end of life, to plan important things, to spend the remaining time of life not only with medical treatments, but to live - these are frequently expressed wishes of people with progressive diseases. Prognostic statements are feared by professionals. At the same time, when talking about what lies ahead for those affected, professionals very often make over-optimistic promises. A broader definition of the term prognosis as well as a careful handling of expectations can help to define realistic goals together.
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Motivação , Cuidados Paliativos , Humanos , PrognósticoRESUMO
Group A Streptococcus (GAS) has acquired an arsenal of virulence factors, promoting life-threatening invasive infections such as necrotizing fasciitis. Current therapeutic regimens for necrotizing fasciitis include surgical debridement and treatment with cell wall-active antibiotics. Addition of clindamycin (CLI) is recommended, although clinical evidence is lacking. Reflecting the current clinical dilemma, an observational study showed that only 63% of the patients with severe invasive GAS infection received CLI. This work thus aimed to address whether CLI improves necrotizing fasciitis outcome by modulating virulence factors of CLI-susceptible and CLI-resistant GAS in vitro and in vivo. Treatment with CLI reduced extracellular DNase Sda1 and streptolysin O (SLO) activity in vivo, whereas subinhibitory CLI concentrations induced expression and activity of SLO, DNase, and Streptococcus pyogenes cell envelope protease in vitro. Our in vivo results suggest that CLI should be administered as soon as possible to patients with necrotizing fasciitis, while our in vitro studies emphasize that a high dosage of CLI is essential.
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Antibacterianos/farmacologia , Clindamicina/farmacologia , Fasciite Necrosante/tratamento farmacológico , Infecções Estreptocócicas/tratamento farmacológico , Streptococcus pyogenes/efeitos dos fármacos , Fatores de Virulência/antagonistas & inibidores , Animais , Antibacterianos/administração & dosagem , Clindamicina/administração & dosagem , Modelos Animais de Doenças , Fasciite Necrosante/microbiologia , Feminino , Humanos , Camundongos Endogâmicos C57BL , Infecções Estreptocócicas/microbiologia , Resultado do TratamentoRESUMO
Group A Streptococcus (GAS) is a human pathogen causing a wide range of mild to severe and life-threatening diseases. The GAS M1 protein is a major virulence factor promoting GAS invasiveness and resistance to host innate immune clearance. M1 displays an irregular coiled-coil structure, including the B-repeats that bind fibrinogen. Previously, we found that B-repeat stabilisation generates an idealised version of M1 (M1) characterised by decreased fibrinogen binding in vitro. To extend these findings based on a soluble truncated version of M1, we now studied the importance of the B-repeat coiled-coil irregularities in full length M1 and M1 expressed in live GAS and tested whether the modulation of M1-fibrinogen interactions would open up novel therapeutic approaches. We found that altering either the M1 structure on the GAS cell surface or removing its target host protein fibrinogen blunted GAS virulence. GAS expressing M1 showed an impaired ability to adhere to and to invade human endothelial cells, was more readily killed by whole blood or neutrophils and most importantly was less virulent in a murine necrotising fasciitis model. M1-mediated virulence of wild-type GAS was strictly dependent on the presence and concentration of fibrinogen complementing our finding that M1-fibrinogen interactions are crucial for GAS virulence. Consistently blocking M1-fibrinogen interactions by fragment D reduced GAS virulence in vitro and in vivo. This supports our conclusion that M1-fibrinogen interactions are crucial for GAS virulence and that interference may open up novel complementary treatment options for GAS infections caused by the leading invasive GAS strain M1.
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Antígenos de Bactérias/metabolismo , Proteínas da Membrana Bacteriana Externa/metabolismo , Proteínas de Transporte/metabolismo , Fibrinogênio/metabolismo , Streptococcus pyogenes/patogenicidade , Animais , Antígenos de Bactérias/genética , Proteínas da Membrana Bacteriana Externa/genética , Proteínas de Transporte/genética , Adesão Celular , Linhagem Celular , Humanos , Camundongos , Camundongos Endogâmicos C57BL , Infecções Estreptocócicas/metabolismo , Infecções Estreptocócicas/virologia , Streptococcus pyogenes/genética , Streptococcus pyogenes/metabolismo , VirulênciaRESUMO
BACKGROUND: Natalizumab, a humanized monoclonal antibody raised against alpha4 integrins, is approved for treatment of active relapsing-remitting multiple sclerosis (RRMS) in adult patients. OBJECTIVE: To determine the safety, effectiveness, and tolerability of natalizumab use in pediatric patients with MS. DESIGN: Case report. SETTING: Center for MS in childhood and adolescents, Göttingen, Germany. PATIENTS: Three pediatric patients with RRMS having a poor response to other immunomodulatory therapies or having intolerable adverse effects. INTERVENTIONS: Natalizumab given every 4 weeks at a dosage of 3 to 5 mg/kg of body weight. MAIN OUTCOME MEASURES: Cranial magnetic resonance (MR) imaging before treatment and every 6 months thereafter. RESULTS: During 24, 16, and 15 months of treatment, no further relapses occurred in the 3 pediatric patients; all reported significant improvement in their quality of life. Follow-up MR imaging showed no new T2-weighted lesions or gadolinium-enhancing lesions. No adverse events were seen when dosage was adjusted to body weight. CONCLUSIONS: Natalizumab treatment was effective and well tolerated in our pediatric patients with RRMS who did not respond to initial immunomodulatory treatments. Therefore, it is a promising second-line therapy for pediatric patients with RRMS.